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U.S. Department of Health and Human Services 

HRSA 

Health Resources and Services Administration 

Center for Health Services Financing and Managed Care 

MANAGED CARE AND HEALTH SERVICES FINANCING 

TECHNICAL ASSISTANCE CENTER 



CONFERENCE PROCEEDING 



May 30, 2002 
Chicago, Illinois 



/ 



Bridging Cultures & Enhancing Care: 

Approaches to Cultural & Linguistic Competency in 

Managed Care 

May 30, 2002 
Chicago, Illinois 

Sponsored by: 

HRSA 

Health Resources and Services Administration 

and 

APHSA 

American Public Human Services Association 



This conference summary reflects the information provided by and the 
opinion of the conference presenters/participants and is not that of the 
American Public Human Services Association, the Health Resources and 
Sendees Administration, or the U.S. Department of Health and Human 
Services. 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



Dear Colleague: 

The Health Resources and Services Administration (HRSA) is pleased to share with you 
the enclosed publication entitled, "Bridging Cultures and Enhancing Care: Approaches 
to Cultural and Linguistic Competency in Managed Care." This publication highlights 
the events of a national conference that was sponsored by the HRSA Center for Health 
Services Financing and Managed Care in cooperation with the American Public Human 
Services Association (APHSA). This conference program covered the core information 
that will enable participants to define and assess the cultural and linguistic competency of 
their organization and provider network. 

Hopefully, this publication will serve as a valuable resource as your organization moves 
toward becoming more culturally competent. Copies of this publication may be 
downloaded from the HRSA Center for Health Services Financing and Managed Care's 
website at www.hrsa.gov/financeMC or ordered from: 

HRSA Information Center 
1-888-ASK HRSA 
www.ask.hrsa.gov 



For more information: 

Please call the HRSA Center for Health Services Financing and Managed Care 
at 1-301-443-1550 or email us at FinanceMC@hrsa.gov. 

To obtain information on other Managed Care and Health Services Financing 
Technical Assistance Center workshops and conferences, please contact: 

Managed Care and Health Services Financing Technical Assistance Center 

1616 North Fort Myer Drive, 1 1 th Floor 

Arlington, V A 22209-3100 

Telephone: 1-877-832-8635 

Fax: 703-528-7480 

E-mail: hrsamctac@jsi.com 

Visit the website at www.jsi.com/hrsamctac 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

INTRODUCTION 4 

CULTURAL COMPETENCY: THE BASICS 5 

The Effects of Race and Ethnicity on the Delivery of Quality Health Care 7 

Building Cultural Competence in Organizations: Focus on Promoting and Sustaining Change.. 10 

Cultural Competence and Linguistically Appropriate Services in the Clinical Setting 12 

Promoting Cultural Competence in Clinical Practice: The Patient-Provider-Interaction 13 

Linguistic Services: Translation and Interpretation Issues 16 

California's Approach to Ensuring Culturally Competent HealthCare Services in Medicaid 
Managed Care and SCHIP Health Plans 19 

SUCCESSFUL PRACTICES IN MANAGED CARE 22 

Arizona Health Care Cost Containment System (AHCCCS) Plans and Provider Pocket Guide. ..22 

A Culturally Conscious Approach to the Delivery of Healthcare Services 24 

Model of Cultural Competency for Working with African American Patients with HIV 26 

Enhancing Family-Centered Care in Managed Care Organizations 29 

Addressing Cultural and Linguistic Diversity in the Community Health Center Environment: 
The Sunset Park Family Health Center Network 3 1 

Project Street Beat, Planned Parenthood of New York City 33 

PLENARY SESSION: AN INTERACTIVE SESSION 
OPPORTUNITY TO DISCUSS CHALLENGES IN DELIVERY 
CULTURALLY AND LINGUISTICALLY COMPETENT HEALTH 
CARE 35 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

INTRODUCTION 

On May 30, 2002, representatives from State Medicaid agencies, managed care 
organizations (MCOs), state and local health departments, Ryan White CARE Act 
HIV/AIDS providers, public hospitals, family support groups, state mental health 
agencies, and others convened in Chicago, Illinois for a conference to discuss the special 
issues related to providing culturally competent healthcare for patients with diverse 
cultural backgrounds. The one-day conference "Bridging Cultures & Enhancing Care: 
Approaches to Cultural & Linguistic Competency in Managed Care" was sponsored by 
the Health Resources and Services Administration (HRSA) Center for Health Services 
Financing and Managed Care in cooperation with the American Public Human Services 
Association (APHSA). 

The conference began with opening remarks from Gregory A. Vadner, Director, Division 
of Medical Services for the Missouri Department of Social Services in Jefferson City, 
Missouri. After general introductions and administrative announcements, the objectives 
for the meeting were set forth. 



Conference Goals and Objectives 
Program Goal: 

To motivate and increase the ability of participants to enhance the cultural and linguistic 
competence within their managed care organization and their provider network(s). 

Program Objectives: 

Program participants will gain an understanding of: 

• The contribution of cultural and linguistic competence to improved health outcomes 

• The business and clinical perspectives for developing culturally and linguistically appropriate 
organizations and services 

• The contribution of culturally and linguistically appropriate services to clinical practice and 
health outcomes through improved provider/patient communication, adherence, early 
diagnosis, and improved prevention. 

• Developing and implementing culturally and linguistically appropriate organizations and 
services 

• The fundamental elements of culturally and linguistically appropriate organizations and 
services 

• Policies, programs, and services which have been developed by managed care organizations 
and/or their provider networks in support of cultural and linguistic competency for adaptation 
and/or incorporation 

• How to implement strategies used to develop cultural and linguistic competence in the 
delivery of healthcare services 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



CULTURAL COMPETENCY: The Basics 

The essential elements of cultural competency were commented on throughout the 
program by all speakers. Felicia Batts* and Josepha Campinha-Bacote** provided 
comprehensive information about the fundamental aspects of cultural competency. Here, 
Drs. Batts' and Campinha-Bacote' s comments have been synthesized and summarized 
in a simple format as a foundation for the remainder of this report. "*" and "**" 
indicate which speaker provided the information. 

What is Cultural Competency?* 

There are as many definitions of cultural competency as there are diverse perspectives, 
interests and needs. However, the following is a broad, generally accepted definition: 

A set of congruent behaviors, attitudes, and policies that come together in a system, 

agency, or among professionals and enable that system, agency or those professionals, to 

work effectively in cross-cultural situations.* 

Cultural competency is based upon the concept that cultural differences extend beyond 
race and ethnicity. Cultural variations include*: 



race 

country of origin 

native language 

social class 

religion 

mental or physical abilities 

heritage 



acculturation 
age 

gender 

sexual orientation 
other characteristics that 
may result in a different 
perspective or decision- 
making process 



Where does Cultural Competency in healthcare begin?* 

Cultural competency occurs in both clinical and non-clinical arenas. 
In the clinical arena, cultural competency is based on the patient-provider interaction. 
In the non-clinical arena, organizational policies and interactions impact the delivery 
of culturally competent services. 

Why is cultural competency important? 

When health care services are delivered without regard for cultural differences, patients 
are at risk for sub-optimal care. Patients may be unable or unwilling to communicate 
their healthcare needs in a culturally insensitive environment, reducing the effectiveness 
of the healthcare process. Understanding the fundamental elements of culturally and 
linguistically appropriate services is necessary when striving for cultural competency in 
healthcare delivery. 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Four Rationales for Cultural Competency in Healthcare Delivery ** 

1. To respond to demographic changes. 

2. To eliminate disparities in the health status of people of diverse racial, ethnic, 
and cultural backgrounds, especially in particular medical conditions: cancer, 
cardiovascular disease, infant mortality, diabetes, HIV/AIDS, and child and adult 
immunizations. 

3. To improve the quality of healthcare services and health outcomes. 

4. To gain a competitive edge in the healthcare market and decrease the 
likelihood of liability/malpractice claims. Healthcare is a business, and as such 
is influenced by the same force driving all big businesses today, including market 
competition, consumerism, organization restructuring, information service 
technology, and customized care. 

What are some obstacles to culturally competent care?* 

Stereotypes, Biases and Assumptions 
Viewing Culture as 'Them', Not Me 
Confounding Race, Culture and Ethnicity 
Differing Health Belief Models 
Patient Exploitation and Oppression 
Pseudo-explanatory Models 
Cultural Mismatches 
Language and Communications Barriers 
Misdiagnosing Ethnic-specific Medical Concerns 
Cultural Clashes 

What are the Pros and Cons of Cultural-Specific Information?* 

Cultural-specific information is one aspect of cultural competency that is important but 
controversial. It can be useful, but misused as well. 

Benefits of Cultural-Specific Information* 

• Can illustrate important differences among cultures 

• Serves as a starting point for cultural assessment of patients 

• Opens mind to alternative viewpoints and treatments 

• Helps avoid egregious errors 

Cautions Regarding Cultural-Specific Information* 

• Tends to promote stereotyping 

• May fail to fully recognize diversity within groups 

• Sometimes creates cultural value scale 

• Can give providers false sense of confidence 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

The Effects of Race and Ethnicity on the Delivery of Quality 
Health Care 

Nathan Stinson, M.D. 

Deputy Assistant Secretary for Minority Health 
Office of Minority Health 
U.S. Department of Health and Human Services 
Rocky ille, Maryland 

Nathan Stinson, Jr., PhD, MD, MPH began the presentations by providing a broad and 
comprehensive overview of how race and ethnicity affect healthcare delivery nationwide 
As our country grows increasingly diverse, health disparities based on race and ethnicity 
are becoming more readily apparent. In 1985, The Task Force Report on Black and 
Minority Health reported that minorities have comparatively poor health, that health 
disparities have worsened and that minorities are chronically underserved by the 
healthcare system. 



The March 2002 report "Racial and Ethnic Disparities in Healthcare" issued by the 
Institute of Medicine (IOM) indicates that these issues have shown little improvement in 
the past 17 years. The most relevant new finding from the IOM may be that racial and 
ethnic disparities remain even after adjustment for socioeconomic differences and other 
healthcare access related factors. The IOM concluded that racial and ethnic disparities in 
healthcare exist and are associated with worse outcomes in many cases. Further, these 
disparities in healthcare occur in the context of broader historic and contemporary social 
and economic inequality, and reflect evidence of persistent racial and ethnic 
discrimination in many sectors of American life. The IOM recommended several 
actions to address healthcare disparities: 

1. Increase awareness of racial and ethnic disparities in healthcare among the 
general public and key stakeholders; 

2. Increase healthcare provider's awareness of disparities; 

3. Initiate legal, regulatory, and policy interventions to enact change. 



Racial and 
ethnic disparities 
remain even 
after adjustment 
for 

socioeconomic 
differences. 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

The IOM report also called for data collection and monitoring according to ethnic and 
racial backgrounds for myriad purposes (see box). 



Why Collect Racial and Ethnic Healthcare Data? 

Evaluate and monitor effectiveness of programs 

Understand etiologic process and identify differences in 

performance within a plan 

Design targeted quality improvement activities 

Develop cost-effective improvement efforts 

Identify the need for and deploy resources for the provision of 

culturally and linguistically appropriate services 

Monitor trends over time at local, state, and national levels 

Help all parties understand the scope of the problem of health 

disparities affecting their clients and stimulate action 

Empower consumers to make informed decisions about health plan 

choice 

Assure civil rights 



However, collecting racial and ethnic information gives rise to some practical and ethical 
issues. There are perceived legal impediments with respect to confidentiality and privacy 
and the potential misuse of data. Further, the cost of large-scale data collection is 
substantial. 

In an effort to address the issues of collecting racial and ethnic information, a meeting 
was jointly held in June 1999 by the Office of Public Health and Science, The 
Commonwealth Fund, the Agency for Healthcare Research and Quality (AHRQ) and 
numerous managed care organizations (MCOs). None of the MCOs in attendance 
routinely collected racial and ethnic information; however, some have obtained such data 
from research, state Medicaid programs or linkages to other databases (e.g, cancer 
registries, birth certificates). While MCOs expressed concerns, the general consensus 
was that if data were to be collected, all plans and health insurers should do it. 

With the assistance of the National Health Law Program, Inc. (NHeLP), a review of state 
and Federal laws was initiated to identify laws and regulations that require or prohibit the 
collection of racial and ethnic data by health insurers and MCOs. Two Federal health 
services programs require racial and ethnic date collection and/or reporting: the End- 

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Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



Stage Renal Disease Program and Substance Abuse and Mental Health Services 
Administration (S AMHSA) applications for prevention service activities. Data collection 
requirements for Medicaid managed care and SCHIP regulations have recently been 
finalized. Several public program statutes also require racial and ethnic data for 
participation. 

Even when a specific statutory requirement does not exist, Title VI of the Civil Rights 
Act of 1964 provides a legal foundation for the collection of racial and ethnic data, 
though it does not specifically mandate or prohibit such data gathering. This Act protects 
individuals by prohibiting discrimination on the basis of race or national origin in the 
provision of any services that are supported with Federal funds. Title VI protection 
extends to all programs and activities of any entity receiving Federal funds, whether or 
not the particular program has itself received or benefited from those funds. This would 
therefore include any Medicaid MCOs. 



Title VI 
provides a 
legal 

foundation 
for the 
collection of 
racial and 
ethnic data. 



State laws for MCOs and health insurers vary, however. Four states prohibit the 
collection of racial and ethnic data as part of the application process: California, 
Maryland, New Hampshire, and New Jersey. Although MCOs are free to collect data at 
the point of care or at some other time after members enroll, it is logistically more 
challenging to generate aggregate data this way. Conversely, one state — South 
Carolina — requires MCOs and insurers to collect racial and ethnic data, while another — 
Texas — requires collection of primary language information. 



After identifying the problem of disparity in healthcare, Dr. Stinson continued to lay the 
foundation for the rest of the day's discussions by defining cultural competency, a 
concept viewed by many as the solution to healthcare inequity. According to Dr. Stinson, 
cultural competency is "the ability of health organizations and practitioners to recognize 
the cultural beliefs, attitudes and health practices of diverse populations and to apply that 
knowledge in every intervention — at the systems level or at the individual level — to 
produce a positive health outcome." He suggests that culturally competent care has the 
potential to improve access to services, reduce medical errors, and increase the use of 
preventive services. Furthermore, cultural competency may improve patient compliance 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

and patient satisfaction, reduce financial costs and liability and ultimately facilitate the 
elimination of health disparities. In closing, Dr. Stinson explained that the Office of 
Minority Health has established 14 national standards to inform, guide, and facilitate 
culturally and linguistically appropriate healthcare services (CLAS). He ended with an 
apt quote from Unequal Treatment: Confronting Racial and Ethnic Disparities in Health 
Care , a report from the National Academies' Institute of Medicine: "The real challenge 
lies not in debating whether disparities exist, but in developing and implementing 
strategies to reduce and eliminate them. Confronting such 'unequal treatment' will 
require a broad and sustained commitment from those who provide care, as well as those 
who receive it." 



Building Cultural Competence in Organizations: Focus on 
Promoting and Sustaining Change 

Calvin Freeman / Organization leaders are 

n ., , / in a position to guide 

President / ,. „ . . 

/ culturally competent 

Calvin Freeman & Associates ' change. 

Sacramento, California 

Calvin Freeman, former Chief of the Office of Multicultural Health and Head of Disaster 
Medical Preparedness for the State of California, addressed the issue of promoting 
cultural competence through organizational change. During Mr. Freeman's 25 years of 
experience in public health, he has found a broad-based, multi-level approach to be 
effective for several reasons. First, organization leaders are in a position to guide a large 
group of people through priority and goal setting. Policies that impact many patients can 
be defined and implemented throughout the organization. Personnel policies and 
decisions can be guided by organizational change. Even the physical design of facilities, 
which is often integral to creating a culturally competent setting, can be addressed. 



Mr. Freeman discussed 4 main strategies for improving cultural competence by 
initiating organizational change: 



10 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

1. Be strategic in your approach to promoting cultural competence. 

2. Build an infrastructure for cultural competence. 

3. Recognize the importance of people and relationships. 

4. Use the management knowledge and tools you use for other issues. 

According to Mr. Freeman, being strategic in an approach to promoting cultural 
competency begins with accepting a few assumptions. First, organizations do not change 
easily because multiple staffs, units and functions are involved. Second, large change is 
built on small steps — we must get away from the idea that everything must be, or even 
can be, accomplished at once. Finally, even failed attempts at change can be positive, 
negative, or both depending on what we choose to learn from the attempts. With an 
understanding of these concepts in place, the first step to promoting cultural competency 
in a large group is to assess the status quo. Assessment helps to define the context and 
environment, identify assets and obstacles, and determine readiness to meet patient and 
community needs. Assessments also send a message to the organization and community 
of the intent to promote cultural competence. Looking forward, assessments set a 
baseline for measuring progress. 

Another component to strategically promoting cultural competence is increasing 
readiness for change. Increasing readiness begins by building internal support for the 
initiative. The support of decision-makers is crucial as they can gradually increase 
acceptance of implementers and mobilize change agents. Mr. Freeman noted that it is 
especially important to manage expectations of staff where change is concerned because 
increasing cultural competency will not happen overnight, and setting expectations too 
high and too fast may result in negative backlash. Credibility is also important and can 
be gained if decision-makers are perceived as actively involved in and committed to the 
same culturally appropriate behaviors they are asking of others in the organization. In 
addition, garnering external support can improve an organization's ability to affect 
change. By engaging a wide mix of allies, understanding their motivations for being 
involved, and encouraging two-way communication, outside groups such as other MCOs, 
hospitals, and public agencies can contribute strength to organizational efforts. 



11 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Building an infrastructure to sustain the cultural competence development process 
includes five key elements, according to Mr. Freeman: knowledge, a planning committee, 
a point person, data and resources. As with any large-scale project, identifying objectives 
and goals with actions and timelines will keep the effort on track. Further, clearly 
identifying current and future resources will help assess the sustainability of the efforts. 

Mr. Freeman noted that while financial resources are an important part of cultural 
competency improvement, human resources are just as valuable. Members at all levels of 
the organization need to believe that these efforts are authentic, will promote better 
delivery of healthcare services and are important to the overall success of the group. 
Praise and recognition are often the strongest way to gain internal support. Acknowledge 
those individuals whose devotion to change is exceptional and unwavering; others will 
likely follow their model. Finally, communicating the strategic plan to the entire 
organization as it develops so that everyone remains "in-the-loop" will strengthen the 
process and help avoid internal conflicts or dissent. ^\ 



Communicating the 
strategic plan to the 
entire organization 
strengthens the cultural 
competency process. 



Cultural Competence and Linguistically Appropriate Services in 
the Clinical Setting 

Felicia Batts, M.P.H. 

President 

Consulting by Design 
Fresno, California 

Ms. Batts shared a comprehensive three-part presentation with the group. The first part, 
"Development of Culturally Competent Services: The Fundamentals" has been 
summarized in the introductory section of this report to serve as primer of basic 
principles and concepts. Part Two (Promoting Cultural Competence in Clinical Practice: 
The Patient-Provider Interaction) and Part Three (Linguistic Services: Translation and 
Interpretation Issues) of Ms. Batts' three-part session focusing on cultural competence in 
the clinical setting are summarized here. 



12 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Promoting Cultural Competence in Clinical Practice: 
The Patient-Provider Interaction 

Patients belonging to minority groups face disparities in accessing and receiving 
healthcare. Many feel that they have difficulty communicating with their physicians and 
that they would receive better care if they were of a different race or ethnicity. Ms. Batts 
explained that healthcare providers have the power to improve healthcare experiences for 
minority patients through culturally competent interactions that promote the delivery of 
quality, timely and effective clinical services to patients of diverse backgrounds. 



First, there needs to be an understanding of the value differences between the Western 
approach to medicine and alternative approaches to which many minorities are accustom. 
In Western medicine, the concept that an individual determines his or her own health is 
generally accepted; this supports the preventive medicine approach and low-power 
distance between patients and providers with a Western medicine mind-set. Patients 
from other backgrounds often view things quite differently. They may perceive health 
and illness as a matter of fate, focusing more on the present state of health rather that the 
future. Frequently, they may believe the physician has the greater power in the 
relationship and therefore avoid asking questions about their own condition. Depending 
on their particular culture and past experiences, patients from minority backgrounds may 
perceive a physician in unique ways. 



Unique Patient Perceptions of Physicians 

Healer/Miracle worker 

Expert 

God's worker 

Shaman 

Confidant or friend of the family 

Authority figure or recipient of unquestioned 

respect 

Pill dispenser 

Last resort for healing 

Someone who inflicts pain 

Partner in making health decisions 



13 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

More and more, all patients, regardless of background, are using alternative therapies. 
Acupuncture and other traditional therapies are being proven effective, and the spiritual 
and mental aspects of disease are receiving more attention now than ever. 
Complementary medicine and alternative health practices are common approaches to 
maintaining wellness and treating illness among patients of diverse backgrounds. One in 
three people have used these methods; however, nearly two-thirds do not tell their regular 
physician about the use of complementary medicine. This is a major concern because of 
potential treatment interactions. In some cultures, patients may view Western medicine as 
a last resort because they feel it is too potent. Providers should discuss complementary 
medicine practices with their patients to gain a better understanding of their perspectives 
and to determine how Western and alternative therapies can be used together to the 
patient's advantage. 

Next, styles of communication may differ among patients from various cultural 
backgrounds — beyond language differences. Considering all types of communication 
(e.g., written, spoken and body language; dialects; and slang) is important to patient- 
provider interactions. Some communication challenges include medical terminology 
versus common terms, varying literacy levels, the speed of speech, culturally 
inappropriate words or phrases, multiple dialects, the use and misuse of interpreters and 
gender-specific terminology. Ms. Batts conveyed that there is no one definitive 
curriculum on culturally competent communication and that she does not train physicians 
in culture- specific methods (e.g., how to interact with Hispanic patients versus Korean 
patients). Instead, she emphasized that those providers who make attempts to learn about 
and understand cultural backgrounds of their particular community of patients are best 
equipped to engage in effective culturally competent communications. However, there 
are some areas of general concern that can be addressed by providers trying to improve 
their interactions with culturally diverse patients (see table). 



14 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



Basic Concern 


Questions to Help Providers Understand Patients 


Names 


How are people named? Do given or family names 
come first? Are titles used? Do names change? 


History 


Why did the family immigrate here? Where from? 
What are conditions in the home country? What health 
problems exist there? What is the work history of the 
family? 


Language 


What language or dialect is spoken? 


Religion 


What are the spiritual beliefs and do they impact daily 
routines? Are there any medical taboos? How does 
religion impact care decisions? 


Moral Beliefs 


What do patients believe about pregnancy, unwanted 
pregnancy, sexually transmitted diseases or similar 
conditions? How does this affect care decisions and 
disclosure to physicians? 


Food 


What foods are common? Are there any taboo foods? 
What are the social rules concerning food? 


Community 


What services are available in the community? Is this a 
unified or divided community? 


Acculturation 


How long has the family/individual resided in the US? 
To what degree has each individual family member 
adopted American culture? 



Understanding patients' family issues also promotes more culturally competent care. The 
family structure and make-up, such as who lives in the household and who are the 
decision-makers, can be important when treating patients. Also, a patient's preferred 
language may be different than that of other family members; likewise the extent of 
acculturation may differ. It is better to get to know each individual rather than making 
assumptions about one family member based on familiarity with another. Also, internal 



15 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

family conflict may impact the care process; therefore, being aware of signs of conflict 
can also guide providers as they treat multiple members of the same family. 

Patient's beliefs may also impact their communication on numerous health-related issues. 
Culturally-held attitudes affect how patients identify a medical problem requiring 
professional attention versus self- or home-care. Patients may also perceive certain 
topics as taboo and feel uncomfortable discussing them, especially if the provider is 
opposite sex. Describing such a problem to the provider can be challenging for patients. 
Further, if patients disagree with the provider, cultural attitudes may inhibit them from 
sharing their concerns. 

Perhaps most important is to establish a level of trust with patients. Discrimination \ 
occurs when trust is absent from both the patient and provider perspective. Physicians 
have limited time to spend with patients, and patients may perceive that physicians are 
driven by profits even if this not actually the case. A basic lack of trust between patients 
and providers results in a lack of trust in the diagnosis or treatment of the medical 
problem. Patients may feel they need to do their own research to validate treatment 
recommendations and be more proactive and aggressive in order to get quality care. 
Providers need to be aware of trust issues and strive to establish a connection with 
patients that will allay their fears. 

Linguistic Services: Translation and Interpretation Issues 

Accessible and appropriate linguistic services are the foundation of culturally competent 
healthcare. Eliminating confusion and achieving clarity with patients is essential for 
ensuring effective communication between patients, providers, and healthcare staff. 
Linguistic services are comprised of four main elements: oral services, interpretation 
services, written services, and translation services. 



Discriminatic 
occurs when 
trust is absei 
from both tht 
patient and 
provider 
perspective. 



There are numerous reasons to provide linguistics and translation services. First, 
language and cultural differences may result in under-use of necessary services. In 
addition, inadequate communication gives rise to concerns about malpractice liability. 
There is also the need to comply with civil rights legislation and pressure from advocacy 

16 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



groups. Several Federal laws exist to ensure access to language services for all limited 
English proficient persons. These laws include Title VI of the Civil Rights Act of 1964, 
the Hill Burton Hospital Survey and Construction Act of 1946, and the 
Disadvantaged Minority Health Improvement Act of 1990. 



There are many options for providing translation services, though the 
effectiveness of these options varies. Healthcare facilities with bilingual 
and bicultural providers and staff are best equipped to provide translational services; next 
most desirable is the availability of the staff members hired specifically for interpretation 
services. When interpretation staff members are assigned other, non-translation duties, 
their job priorities are divided. Thus, while this may be a financial beneficial strategy, it 
is not the optimal one for patients in most clinical settings. The use of outside 
interpreters or telephone interpretation may be required, but again is not the preferred 
method. Finally, last resorts include the use of family members for translation or 
referring the patient to another facility; neither strategy is in the best interest of the 
patient or the healthcare organization providing services. 



There are many options for 
providing translation 
services, though the 
effectiveness of these 
options varies. 



Having bilingual and bicultural staff allows direct communication between staff members 
and patients, which reduces miscommunication and misunderstanding. However, there is 
a lack of qualified providers and staff, even for common languages. Further, there is no 
standardized tool to assess language and cultural skills. Dialects and language 
differences related to socioeconomic status may still exist, and translating medical 
terminology in the target language can be a problem. While building a bilingual staff and 
provider group is not a perfect solution, it is the best practical option for serving patients 
in a culturally competent manner. 

An "Interpretation-Only" staff offers several benefits, as well. These individuals are 
more likely to be skilled at medical interpretation, having had didactic training in the 
field. Also, this option also offers flexibility in hiring practices. However, it works best 
in a setting with high demand for a single language versus one with linguistic diversity of 
patients. Again, there is a lack of defined standards in this area, and finally, it can be a 
costly option. 



17 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



Hiring an interpretation staff person with other duties is a reasonable alternative when the 
demand is not sufficient to hire someone full-time. Interpreters can be effective as 
caseworkers or family health workers, roles where communication is essential. However, 
care must be taken to avoid conflicts between interpretation services and other duties so 
that staffers are not confused as to work priorities. If the staff person is used only 
occasionally for interpretation, costs are reduced and there is someone on-site in an 
emergency. But this is really only a contingency plan, because maintaining accurate lists 
of employees who speak particular languages is difficult and it may be challenging to 
locate that person when he or she is needed, especially in larger facilities. This option 
also bears the greatest potential for job conflicts. 

Using outside interpreters can be effective when there insufficient demand for a full-time 
staff member. These interpreters can be hired hourly for prescheduled appointments and 
can supplement on-staff interpreters as needed. Again, the lack of standards is an issue, 
and hourly rates can be expensive. Further, there is no established relationship with the 
provider, and outside interpreters may be difficult to access on short notice, so they 
cannot be used in an emergency. 

The use of telephone interpretation services is especially appropriate for emergency 
situations, or if brief or basic information is needed. But few telephone translators are 
medical specialists, so they may lack cultural health knowledge. Also, body language 
and similar communication clues are lost with this method. 



Finding the option that works will be individual for each healthcare 
setting and will depend upon numerous factors. But doing so is crucial because 
a lack of translational services or poor translational practices can result in major 
dilemmas, such as cultural misunderstandings, incorrect assessment of patient's 
language ability, and confidentiality conflicts. The use of family members, 
especially children, is highly undesirable because of the potential for family 
conflict or the impact of the information being conveyed. 



The use of family 
members for 
translation, 
especially 
children, is highly 
undesirable 
because of the 
potential for 
family conflict or 
the impact of the 
information being 
conveyed. 



18 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Several new approaches for selecting an interpretation method are now available, thanks 
to research regarding the impact, effectiveness, and cost-benefits of various strategies. 
Also, technology has evolved to allow video conferencing translation and computer 
software has been developed to aid with translation needs. 



California's Approach to Ensuring Cultural Competent 
Healthcare Services in Medicaid Managed Care and SCHIP 
Health Plans 

Gregory A. Franklin, M.H.A. 

Chief, Office of Multicultural Health 
California Department of Health Services 
Sacramento, California 



Gregory A. Franklin, M.H.A., Chief of the Office of Multicultural Health, discussed how 
purchasing strategies and the application of policy have provided the foundation for the 
delivery of culturally and linguistically appropriate healthcare services in Medicaid and 
State Children's Health Insurance Program (SCHIP) managed care organizations (MCOs) 
in California. Mr. Franklin began by reviewing the definition of cultural competency 
(see Introduction), and by discussing a framework for health. Personal health begins with 
the individual at the center of many other interactive variables (see figure). Policymakers 
have not only the ability, but also the responsibility to contribute to this process in a 
positive manner. 



Determinants of Health 



Policies and Interventions 



f 



Physical 
Environment 



1 




Behavior 



Individual 



Biology 




Social 
Environment 



Access to Quality Healthcare 



19 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

The ethnic and racial composition of Californian residents is rapidly changing; therefore, 

cultural competency will play a large role in the process of determining health. While the 

white, African American, and Native American populations are decreasing, the number 

of Hispanic Americans and Asian or Pacific Islanders is growing simultaneously (see 

figure). 

The Changing Ethnic and Racial Composition of California 

60% 



s 

CL. 




H 1990* 



II 2000** 
■ 2040*** 



1 II 



White 



Hispanic Asian/PI Black Native Am. 



* California Department of Finance 1990 Census Data 

** US Census Data 2000 

*** California Department of Finance Census Projection Data 1990 



Medi-Cal, California's Medicaid Managed Care, includes a significant portion of this 
diverse population. As of April 2002, Medi-Cal enrollment was nearly 2.6 million, of 
which 45% of members are Latino/Hispanic, 18% African American, and 10% Asian/ 
Pacific Islanders. The Healthy Families Medi-Cal for Children program, SCHIP, 
includes an additional half-million members with a slightly different ethnic and racial 
make-up: Latino (66.7%), white (15.9%), Asian Pacific Islander (13.4%), and African 
American (2.9%). The larger portion of Latino and Hispanic children enrolled through S- 
CHIP reflects the recent growth of this group. 

To ensure culturally competent, quality health services are delivered to these members, 
Medi-Cal has partnered with a range of organizations to enhance care. These groups 
include: 



20 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



• Health Advocates 

• Hospitals 

• Managed Care Organizations 

• Community Clinics 



• Academia 

• Legal Aide Society 

• Immigrant Rights Organizations 

• State Health Programs 

• Provider Organizations 



Mr. Franklin noted several important policy considerations that can support efforts to 
improve healthcare for California residents. First, the concept of "health" itself should be 
broadly defined in positive terms in order to stimulate proactive, preventive interventions. 
Secondly, patients and providers need to recognize that the health is determined by 
sociocultural and economic issues as well as physical factors. And as previously noted, 
California's changing demographics will have long term effects on policies that impact 
healthcare delivery. 



With these considerations in mind, Medi-Cal has developed and disseminated numerous 
policy letters for providers and provider groups in the Medi-Cal network. The policy 
letters address issues such as linguistic services, translation of written informing material, 
Community Advisory Committees, and needs assessments. To meet the needs of a 
culturally and linguistically diverse population, Medi-Cal has identified "threshold 
languages" (languages common to a significant portion of the patient population) and 
requires that written material and oral translational services be available in these 
languages. Members have been informed of these services. Medi-Cal groups have been 
asked to establish a Community Advisory Committee for recruiting membership and 
identifying the group's function. For translation of written informing materials, 
healthcare groups are required to create linguistically accessible documents and/or 
timeline for the creation of such materials. 



Despite these efforts, some challenges still exist in delivering 
culturally competent care. There is no "one size fits all solution" for 
every provider or practice in the Medi-Cal system. Though 

21 



Despite these efforts, 
some challenges still 
exist in delivering 
culturally competent 
care. There is no "one 
size fits all solution" for 
every provider or 
practice in the Medi-Cal 
system. 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

enforcement and accountability are important, practical issues sometimes impede 
required activities. Other obstacles include competing priorities (i.e., the will of health 
advocates vs. state policy), access issues, and lack of dedicated funding. 

Still, the future of quality healthcare depends on continued efforts to overcome these 
obstacles and bring culturally competent care to every Medi-Cal member throughout the 
state. Medi-Cal plans to incorporate policies throughout the state health department and 
make policies and processes available to other state agencies. As they continue to refine 
existing efforts in managed care, Medi-Cal would also like to develop fee-for-service 
models for enhancing culturally competent care. Finally, the organization plans to step 
up its efforts to monitor for compliance with these important policies. 



SUCCESSFUL PRACTICES IN MANAGED CARE 



Arizona Health Care Cost Containment System (AHCCCS) Plans 
and the Provider Pocket Guide 



Georgia Hall, Ph.D., M.P.H. 

Executive Director 

Institute for Health Professions Education 

Phoenix, Arizona 

Philip Nieri, MP A 

Director of Compliance 
Schaller- Anderson, Inc. 
Phoenix, Arizona 

Georgia G. Hall, PhD, MPH and Philip Nieri, MPA discussed how Arizona's Medicaid 
program (AHCCCS) developed a cultural competency provider-education initiative in 
conjunction with its many contracted health plans throughout the state. AHCCCS 
subcontracts with health plans owned and/or managed by Catholic Healthcare West, 
CIGNA, United Health Care, Schaller Anderson, Inc. and various hospital based health 

care companies (e.g. IASIS Healthcare and Vanguard). These companies help manage 

22 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

services provided to 650.000 members in all Arizona counties. Members choose a plan 
and PCP to act as their "medical home". 

Because of the many separate entities involved in serving the AHCCCS patient 
population, the challenge was to create a plan that would improve provider awareness of 
cultural competency issues across the entire network. By believing that culturally 
appropriate care improves health outcomes and helps eliminate health disparities, 
AHCCCS and its subcontractors met that challenge head on. AHCCCS requires its 
health plans to participate in quality improvement efforts in both clinical and non-clinical 
areas that would be expected to have a beneficial effect on health outcomes and member 
satisfaction. One of these areas is cultural competency of services. 

AHCCCS. with its subcontractors, established a framework for a cultural competency 
workgroup to coordinate compliance with cultural competency program requirements, 
including those imposed federally and by the state. The workgroup helped coordinate 
the development of annual cultural competency work plans and methods for reporting 
outcomes from the Cultural Competency Quality Improvement Project. The workgroup 
includes representatives from all AHCCCS health plans and program contractors from 
various sectors including compliance, quality management and operations. By engaging 
in discussions on compliance and by sharing "best-practices" ideas, the workgroup 
identified a strategy for action. The core idea was to reduce redundancy of culturally 
competent activities, particularly training and outreach to physicians, and develop new 
efforts to supplement existing training/outreach resources. A sub-committee was 
subsequently created by those health plans and programs contractors who volunteered to 
help. 

The sub-committee focused on development of a cultural competency "pocket guide" to 
be distributed to every provider in an AHCCCS health plan. A consultant was hired to 
gather information about educational needs in providing culturally competent care and to 
ensure that information in the guide reflected AHCCCS requirements. The sub- 
committee also coordinated the printing/distribution of the guide for participating 
provider offices. Though it required significant coordination between the state and many 

23 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

individual health plans, the project presented a unique opportunity to jointly develop a 
useful resource for providers, proving that collaborative projects can work — in spite of 
competition and other perceived barriers. 



A Culturally Conscious Approach to the Delivery of Healthcare 
Services 

Josepha Campinha-Bacote, PhD, RN, CS, CNS, CTN, FAAN 

President 

Transcultural C.A.R.E. Associates 

Cincinnati, Ohio 

Josepha Campinha-Bacote, PhD, RN, CNS, BS, CTN, FAAN, President of Transcultural 
C.A.R.E. Associates, shared with the group the ASKED model of cultural competence, 
which she developed and published in 1998. According to Dr. Campinha-Bacote, 
cultural competency is the "process in which the healthcare provider continuously strives 
to achieve the ability and availability to effectively work within the cultural context of a 
client (an individual, family, or community)." Emphasizing the "process" aspect of her 
model, she states that cultural competence is a journey, not a destination; it is cyclic not 
linear. 

The process of Cultural Competence involves interrelationships between five 
elements: 

Cultural Awareness 

Cultural ^kill 

Cultural IVnowledge 

Cultural rencounters 

Cultural Desires 
Hence, the ASKED model. 

24 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



Cultural awareness requires "self-evaluation of one's own prejudices and biases towards 
other cultures. [It is] the process of cultural humility." 1 It is also a willingness to explore 
one's own cultural and ethnic background. Basically, says Campinha-Bacote, cultural 
awareness means knowing yourself. On a broader level, this concept entails asking the 
question, "Is there racism in the delivery of healthcare services?" Dr. Campinha-Bacote 
cited several evidence-based studies that confirm that such racism does in fact exist. 

Cultural knowledge includes obtaining a sound educational foundation concerning the 
various world views of different cultures. Within the field of healthcare, it also means 
obtaining knowledge of "biocultural ecology" — biological variations, disease and health 
conditions and variations in drug metabolism related to one's background. Dr. 
Campinha-Bacote warns, though, that it is necessary to be wary of intra-ethnic and intra- 
cultural variations; even within cultural groups, many differences exist. 

Cultural skill is the ability to collect culturally relevant data regarding a client's health 
history and current medical problem. This is done using a cultural assessment tool. 
Conducting a culturally-based physical examination is also part of cultural skill in 
healthcare. These assessments should be conducted in a culturally-sensitive manner. Dr. 
Campinha-Bacote reminded the audience that everyone should be given a cultural 
assessment. Only conducting an assessment with patients who "look like" they might 
need one is a culturally bias practice itself. A cultural assessment tool is available in Dr. 
Campinha-Bacote 's book, The Process of Cultural Competence in the Delivery of 
Healthcare Services . 2 The ultimate goal of a cultural assessment is to determine 
appropriate culturally responsive interventions, which ask providers to recognize the 
differences in individuals, but build upon similarities to others. 

Another element of the process is the cultural encounter. Cultural encounters are the 
process by which healthcare providers directly engage in face-to-face, cross-cultural 
interactions. The goals of these interactions are to generate a wide variety of verbal 



1 Tervalon, 1998 

2 Campinha-Bacote, J. "Cultural Skill" in The Process of Cultural Competence in the Delivery of 
Healthcare Services. 1998, 3 rd edition. OH: Transcultural C.A.R.E. Associates. 

25 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

responses (i.e., encourage patients to communicate openly) and to send and receive both 
verbal and non-verbal messages accurately and appropriately in each culturally different 



context. 



Cultural Desire is not necessarily 
a learned behavior; rather, it is 
based upon provider's internal 
motivation to engage in the 
Cultural Competency process. 



Perhaps the most vital component of the ASKED model is 
cultural desire. This, unlike the other four elements, is not 
necessarily a learned behavior; rather, it is based upon provider's internal motivation to 
engage in the cultural competency process — because they want to, not because they have 
to. Characteristics of a provider who has cultural desire include compassion, 
authenticity, humility, openness, availability, and flexibility. Dr. Campinha-Bacote 
emphasizes that skill, knowledge, and awareness matter very little without desire: 
"People (i.e., patients) don't care how much you know until they first know how much 
you care." 

One application of the ASKED model of cultural competence is the BE SAFE model, a 
culturally competent model for caring for African Americans with HrV/AIDS. Following 
Dr. Campinha-Bacote 's presentation, her colleague John McNeil, MD, Principal 
Investigator for National Minority AETC in Washington, D.C., describe the BE SAFE 
model. 



Model of Cultural Competency for Working with African 
American Patients Infected With HIV 

John McNeil, MD 

Principal Investigator 
National Minority AETC 
Washington, D.C. 



John McNeil, MD, Principal Investigator for the National Minority Aids Education 
Training Center (AETC) in Washington, D.C, discussed cultural competency in a very 
specific context: caring for African Americans with HIV or AIDS. Dr. McNeil noted 
that people of African decent who reside in the United States are a hybrid population. 



3 Adapted from Sue, 1982 



26 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Most African Americans have genetic make-ups that cross African ethnic groups and 
other racial groups, primarily European and American Caucasian, as well as Native 
American. Caribbean population mixtures include East Indians, Chinese, and Indigenous 
West Indians. Nearly one million individuals have emigrated from nations in Africa and 
the Caribbean since 1994, with Florida, New York and New Jersey being the most highly 
populated areas. Within the African American community, many cultural differences 
exist, and recognizing these differences is vital to providing culturally competent 
healthcare. 

Moreover, providing culturally appropriate care for African American patients with HIV 
requires a unique sensitivity to issues that transcends race or ethnic background. There 
are shared behaviors and issues that create a culture associated with the disease itself. 
Patients with HIV/AIDS experience emotional distress, sexual orientation issues, 
economic hardship, and societal discrimination. They may also participate in high-risk 
behavior and substance abuse as part of their daily lives. Understanding and addressing 
these issues is vital to providing culturally competent care. 

The National Minority ADDS Education and Training Center developed a model of 
cultural competency for African American patients with HIV/AIDS. A multidisciplinary 
panel comprised of physicians, nurses, dentists, physicians' assistants, and HTV educators 
was organized; the panel included a heterogeneous mix of individuals born in America, 
the Caribbean, Africa, and Cape Verdean. The primary aims of the panel were to 1) 
encourage a deeper understanding of cultural competency as it relates to the HIV infected 
patient, 2) assist clinicians working with HIV-infected patients to develop their 
understanding of intra-ethnic variations, and 3) develop an understanding of the role HIV 
plays in values, beliefs, and customs of a patient. These aims were achieved through the 
development of the model and dissemination of information to care providers. 

The result of the panel's efforts was the BE SAFE model for culturally competent care 
for African American patients with HIV/AIDS. The model is based upon the principles of 
Josepha Campinha-Bacote's model of cultural competency. BE SAFE is an acronym for 
six major factors that influence the quality of care these patients receive: Barriers, Ethics, 

27 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Sensitivity of providers, Assessment, Facts, and Encounters. Providers are encouraged to 
consider all elements of the model in their daily practice. The BE SAFE model is 
detailed in the figure below; each list identifies major issues to consider during each step 
of the BE SAFE process of culturally competent care. 



B 


E 


Barriers 


Ethics 


Prejudices 


Third Party Notification 


Socioeconomics 


Responsibilities 


Ethnicity 


Desire 


Stigma 


Humanizing 


Mistrust 


Confidentiality 


Geography 


Truth Telling 




Difficult Patients 




Dying Patients 




Professionalism 




HIV Specific Ethics 




Patient's Rights 



s 


A 


Yj- 


E 


Sensitivity 


Assessment 


Facts 


Encounters 


Provider Biases 
Stigmas 

Self-Exploration 
Cultural Imposition 
Unpopular Patients 


Physical 

Emotional 

Spiritual 

Social 

Mental 

Occupational 


Purnell's 12 Domains 

Values 

Beliefs 

Practices/Customs 

World Views 

Biocultural Ecology 


Encounter Strategies 

Case 

Presentations/Studies 

Language/Communication 

Do's and Don'ts 

Establishing Cultural 

Communication 



28 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



Enhancing Family-Centered Care in Managed Care 
Organizations 

Sophie Arao-Nguyen, PhD 

Cultural Competency Consultant 
Parents Helping Parents, Inc. 
San Jose, California 

In California, a dramatic population shift is occurring: while the percentage of African 
Americans remains stable and the proportion of whites decreases, the number of Asian 
and Hispanic Americans is rapidly rising. Further, the number of recent mixed-race 
births is also climbing, with more than 70,500 biracial children born in 1997 alone. 
Healthcare plans and community groups in this increasingly diverse state have thus 
turned their attention to devising ways of offering more culturally competent care to its 
members. 



Parents Helping Parents (PHP), 
a parent-directed family resource 
center, and Kaiser Permanente, 
a managed care facility, joined 
forces to create a national model 
for introducing family-centered, 
culturally competent services for 
Children with Special Health 
Care Needs (CSHCN) into 
managed care. 



Parents Helping Parents (PHP), a parent-directed family 

resource center, and Kaiser Permanente, a managed care 

facility, joined forces to create a national model for 

introducing family-centered, culturally competent services for 

Children with Special Health Care Needs (CSHCN) into 

managed care through a collaborative consumer/provider 

partnership. Sophie Arao-Nguyen, Ph.D., cultural competency consultant and PHP 

Advisory Board Member, described this exciting and successful initiative. 

In 1994, PHP and Kaiser Permanente received a 4-year SPRANS grant (Special Projects 
of Regional and National Significance) to develop and assess this model. When children 
with special needs visited Kaiser Permanente's offices in Santa Clara and Santa Teresa, 
California, physicians referred parents to PHP as a supportive resource. In turn, PHP 
hired and trained a parent liaison, working through Kaiser Permanente, to enroll and 
support parents who sought out their services. PHP services include information and 
education, mentor parents, support groups by disability and by language, and translation 
services. In addition, PHP trained Kaiser Permanente physicians, nurses, social workers, 

29 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

and other staff members in seminars such as "Better Ways of Breaking Diagnostic 
News", "The Modern Art of Caring for Families", and "The Heart of Family-Centered 
Care". 

This model was so successful that after four years, Kaiser Permanente decided to fund the 
program when the SPRANS grant was complete. Parents reported satisfaction with the 
services that were offered by Kaiser Permanente and PHP. Efforts to replicate this 
successful model at two other managed care facilities began in 1998 through a grant 
funded by the HRSA Maternal and Child Health Bureau (MCHB). This grant, which 
ended in June 2002, allowed PHP to partner with Good Samaritan Hospital, a private 
managed care organization, and Valley Medical Hospital, a government-run hospital, to 
enhance family-centered, culturally competent care. At the time of this presentation, 
negotiations for continued funding through Good Samaritan and Valley Medical 
Hospitals were on-going. Plans to replicate this model with other hospitals in the San 
Francisco Bay Area are currently being explored. 

Experiences with the PHP/Kaiser Permanente project provided several important lessons. 
First, it is crucial for community resource groups to build relationships with the managed 
care organizations serving the group's members. Establishing trust and mutual respect 
through open communication is key, and can be facilitated by identifying "champions" 
within the managed care system. Secondly, a referral system that works for both entities 
is an important component for success. Establishing an Advisory Board composed of 
representatives from the managed care organization and the parent organization helps 
ensure that the goals and needs of both groups are met. Further, reliable technology and 
support for gathering quantitative and qualitative data is necessary to show improved 
outcomes in terms of health and/or patient satisfaction as well as cost-effectiveness. 
These lessons will provide the framework for potential models in the future. 



30 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

Addressing Cultural and Linguistic Diversity in the Community 
Health Center Environment: The Sunset Park Family Health 
Center Network 

Molly McNees, Ph.D. 

Staff Medical Anthropologist 

Sunset Park Family Health Center Network 

Brooklyn, New York 

Molly McNees, Ph.D. spoke to the group about Sunset Park Family Health Center 
(SPFHC) Network, a group of Federally-funded community health centers in and around 
Brooklyn, New York. The Network grew out of a single community health center 
established in 1967. The original OEO Neighborhood Health Center was based upon the 
Community Oriented Primary Care Model and has maintained a long tradition of assuring 
quality care by measuring clinical outcomes since 1990. Today, the vision of Sunset Park 
Family Health Center Network is to improve the overall health and well-being of the 
communities served by delivering high quality, culturally-competent primary care and 
related services within community-based settings. 
The outcomes for which Sunset Park strives are three-fold: 

•Quality services that are competitive in a managed care environment 
•Highly satisfied patients with improved health and well being 
•High levels of staff satisfaction 

The communities that SPFHC Network cares for are generally medically underserved. In 
terms of insurance, 30 percent are enrolled in Medicaid, 25 percent in managed care, 
while 13 percent have private insurance, and 10 percent are covered by Medicare. A full 
22 percent of SPFHC Network patients are uninsured. The patients reside in an urban, 
inner city environment. Seventy-eight percent live below 125 percent of the Federal 
poverty level. Twenty-five percent of patients (or 123,000) lost their Medicaid eligibility 
in Manhattan and now seek treatment in Brooklyn. Nearly 700,000 are uninsured 
Brooklyn residents. 

The current SPFHC Network consists of 8 primary care centers, over 20 community and 
provider partnerships, and 13 school-based centers. Patient membership exceeds 90,000 

31 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

users who make more than 575,000 annual visits. The ethnic mix of SPFHC Network 
closely reflects the communities it serves; 55 percent of patients are Hispanic, 12 percent 
Asian and Pacific Islander, 7 percent African American, and 26 percent white. With a 
high immigrant population, 40 percent of patients are limited English speakers. The 
SPFHC Network has several facilities that primarily serve patients of specific 
backgrounds based on the neighborhood composition. 

For example, the Family Physician Health Center, one of the eight Sunset Park centers, 
mainly cares for Hispanic patients because it is geographically located in a mostly 
Hispanic neighborhood. Similarly, the Park Ridge Family Health Center offers multi- 
ethnic outreach and provides an Islamic prayer room, fish tanks (which are an Asian sign 
of good health) and complementary medicine services. There is also a Caribbean 
American Family Health Center in the Network. The SPFHC Network has also begun an 
Asian Initiative, which includes community partnerships and a needs assessment. 
Language access has been addressed by creating more culturally appropriate signage and 
translating written material. Staff development, including in-service training to staff, a 
new culturally competent hiring policy, and foreign nurse training, is another component 
of the Asian Initiative. The New Brooklyn Chinese Family Health Center is the primary 
care site for Brooklyn's Chinese community. Network-wide language access strategies 
have also been instituted, addressing patients who speak English, Spanish, Chinese 
dialects, Arabic, Russian, Haitian, and Creole. 



SPFHC offers 
residency for new 
physicians training 
with a curriculum 
in cross-cultural 
health care. 



In addition, SPFHC offers residency for new physicians training with a curriculum in 

cross-cultural health care. Integrated with Family Practice 

Residencies, this didactic and experiential curriculum teaches 

communication skills, such as patient-centered interviewing and 

medical anthropology. SPFHC Network is also engaged in 

research related to cultural competency. The Mexican Health 

Project, conducted in conjunction with Barnard College at Columbia University, is a 

multi-method study examining health issues and disparities in the Hispanic communities. 

Areas of focus are healthcare needs and experiences, reproductive expectations and 

experiences, folk medicine and self-care, and diabetes management. Study methods 

32 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

include a cross-sectional survey, intensive patient interviews, ethnography, and focus 
groups. This study is supported by United Hospital Fund, CAP and HRSA Disaster 
Assistance. 

Dr. McNees concluded her presentation by stating that SPFHC Network will continue its 
mission to enhance culturally competent care in order to meet new State and Federal 
mandates, tap new patient markets, achieve quality and satisfaction for patients and staff, 
and improve clinical outcomes. 



Project Street Beat, PPNYC 

Daphne Hazel 

Associate Vice-President 

Project Streetbeat, Planned Parenthood of New York City 

Bronx, New York 



HIV and AIDS are a serious threat to the underserved, culturally diverse community 
living on the streets of Bronx, New York. Daphne Hazel, Associate Vice-President of 
Project Street Beat, described this program from Planned Parenthood that tackles 
HIV/AIDS on its own turf. Project Street Beat's mission is to reduce the rate of HIV 
transmission by empowering communities of color and others to change risk behaviors 
and to receive HIV care-related services. The uniqueness of Project Street Beat is that 
treatment, education, and outreach are delivered straight to the streets of the South Bronx 
where teens and young adults are at greatest risk. 

Project Street Beat started in 1988 in the South Bronx, but now includes consolidated 
services in Brooklyn, Queens, Bedford, and Northern Manhattan. The individuals served 
through Project Street Beat are predominantly black (55%) or Latino (43%); the ratio of 
males to females is nearly equivalent. Thirty-percent of patients are between the ages of 
14 and 25, with 69% age 25 and older. The target population is at high risk for 
HTV/AIDS because of the nature of their activities: 8% are commercial sex workers, 
52% use intravenous drugs or other substances, 30% are adolescents, and 6% are other 
"hard-to-reach" populations including men who have sex with men, transgender or 
transsexual individuals, or parolees. 

33 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 



The concept behind Project Street Beat is for an outreach team to establish a presence on 
the street and offer practical help on the spot. The outreach teams build relationships with 
clients based on trust and develop a rapport with clients' allies, who may include pimps, 
drug dealers, abusive partners, family, and friends. Gaining the support of allies is 
essential because they can be influential in promoting or negating the healthy practices 
Project Street Beat teaches. 

The Outreach Teams explore the target areas to identify the "hot spots", areas where drug 
dealing or sex peddling occurs. Once there, the teams conduct impromptu "focus 
groups" by engaging potential clients in conversation about what Project Street Beat is all 
about. The teams continue to cultivate the areas by repeatedly visiting and establishing a 
familiar presence. Van Outreach and Mobile Medical Unit Outreach offer various levels 
of care from oral HF/ testing to gynecological exams and birth control. 



Project Street Beat is built on the premise that culture is not limited 

to race and ethnicity; rather, it includes customary beliefs, shared 

attitudes, values, practices, and integrated patterns of behaviors. The staff 

reflects the racial and ethnic make-up of the target population with 1 8 

African- American staffers and 12 Latino staff members. They also have 

employees who speak English, various Spanish dialects, and Creole. The staff is diverse 

in their ages, life experiences, sexual orientation, and professional backgrounds. Project 

Street Beat also hires Peer Educators who are former drug abusers or sex workers living 

with HIV. 

Applying cultural competence in this environment means understanding the clients' 
needs and motivations. For example, because sex is currency in the drug economy of the 
street, using a condom can mean making less money or putting oneself at risk for 
violence. For this reason, outreach strategies must be creative, such gaining the 
acceptance of a client's pimp or abusive partner or by making arrangements to meet the 
client in a safe place. With adolescents who are often outcast from troubled families and 
who are wary and rebellious, cultural competence means understanding that these clients 

34 



Project Street Beat is 
built on the premise 
that culture is not 
limited to race and 
ethnicity; rather, it 
includes customary 
beliefs, shared 
attitudes, values, 
practices, and 
integrated patterns of 
behaviors. 



Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

may not trust adults. In these cases, outreach may include gaining the trust of a leader in 
the group whom other teens tend to follow. 

Project Street Beat does not act alone; the group collaborates with numerous community 
agencies to meet their clients' needs. These collaborators include AIDS centers and 
hospitals, detoxification centers, drug rehabilitation centers, substance abuse programs, 
community health centers, maternal/child centers, legal and social services, housing, food 
banks, faith-based organizations, and other community-based organizations. 

Project Street Beat's 14-year history is a testament to its success, as are some of its more 
recent accomplishments. In 2001, Project Street Beat made a difference in the lives of 
many people living and working on the streets of New York City, as the following figures 
reveal: 

Project Street Beat Accomplishments in 2001 : 

Served 24,295 people in need of care 

4,053 harm reduction counseling sessions 

1,349 HIV tests 

719 post-test HIV counseling 

479 medical exams 

4,476 referrals 

422 case management clients 

240 support groups and presentations to community based organizations 



PLENARY SESSION: An Interactive Session Opportunity 
to Discuss Challenges in Delivering Culturally and 
Linguistically Competent Health Care 

The day-long program culminated in a plenary session during which three panelists 
(Felicia Batts, Josepha Campinha-Bacote, and Calvin Freeman) addressed challenging 
areas identified by the audience that can arise when developing culturally and 
linguistically appropriate services and programs. In an interactive session, these expert 

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Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

facilitators led a discussion on approaches that can be used to address those issues raised 
by the audience. The audience provided questions, and panelists facilitated a discussion 
to provide answers. The questions and resultant group answers are summarized in this 
section. 



1 . Please comment on strengths/weaknesses of implementing 
cultural competence initiative through a Quality Improvement (Ql) 
committee. 

For managed care organizations, QI committees are a logical place to introduce 
cultural competency initiatives because these committees have a broad influence on 
what happens in the whole organization and because QI committees focus on 
measurement and outcomes, so initiatives would more likely be assessed to show an 
actual impact on patient care or organizational processes. Also, implementing 
cultural competency through QI guarantees that the high-level executives at the 
hospital or MCO will be included in these initiatives. 

The California Department of Health Services (CDHS) is an excellent resource for 
community-based groups looking for information in this area; CDHS has developed 
policy letters that address how to develop a cultural competency quality improvement 
initiative. Importantly, access to accurate racial and ethnic data will be crucial to the 
success of QI projects. Health plans may be able to get this type of data through 
collaboration with state agencies. 

2. As a coordinator of a Substance Abuse and Mental Health 
Services Administration grant focusing on mental health 
disparities in the Russian and Latino community, what are some 
suggestions you have for training to encourage cultural 
competence of primary care providers? 

One overriding challenge in mental health is that psychiatric conditions are often 

viewed as not as important as diagnoses of physical conditions, such as diabetes or 

asthma, when in fact both types of conditions impact one another. This bias, 

combined with cultural competency challenges, poses a significant dilemma for 

mental health therapists and their clients. One participant suggested that medical 

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Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

schools and residency programs are one arena in which to strive for improvements. 
Primary care and mental health specialists who can discuss cultural competency may 
be effective as consultants to introduce cultural competency early in medical 
education so as to instill new paradigms in the future healthcare professional 
community. 

Another participant responded that in the rural area where she works, cultural 
competency issues are not well understood or accepted by veteran physicians, and 
finding a cultural competency consultant is difficult. The HRSA Managed Care and 
Health Services Financing Technical Assistance Center is one resource for providing 
such training. Offering Continuing Medical Education (CME) credits in cultural 
competency will also draw physicians of all ages to attend training sessions. Ms. 
Batts commented that many physicians need CME credits specifically in the category 
of ethics, so as ethics-oriented CME programs are developed, there needs to be 
greater focus on cultural competency. 

3. What is the difference between Hispanic and Latino? Is one more 
culturally sensitive or correct? Does one encompass all people 
of Spanish descent? 

There was no consensus on this issue. The terms 'Chicano', 'Hispanic', and 'Latino' 
were discussed. Though 'Chicano' is used rarely now, the difference between the 
other terms was less clear. The preferred term may vary by region and by individual. 
It is best to know the general preference of community you serve, but to accept that 
from patient to patient, attitudes may differ. Self-definition should be respected. 
More importantly, if patients know that their providers care about and respect them, 
the political correctness of terms used will most likely not be challenged. 

4. Are certain diseases found more frequently among particular 
ethnic populations? What common misdiagnoses exist 
according to ethnicity? 

Cultural competency is not just about values, beliefs and attitudes; there are 
biological and clinical issues that are relevant. But there is still considerable 
controversy about whether widespread genetic variation exists among ethnic and 

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Bridging Cultures & Enhancing Care: Approaches to Linguistic & Cultural Competency in Managed Care 

racial groups. It is well-established that certain diseases are more prevalent in certain 
groups. One participant expressed concern about misdiagnosis of these diseases. 
Certain "cultural-bound illnesses", particularly in the mental health arena, are an 
example. Dr. Campinha-Bacote stated that there is national evidence that people of 
color are more often misdiagnosed with thought-disorders, such as schizophrenia, 
whereas whites are more often diagnosed or misdiagnosed with mood disorders, such 
as depression. In addition, another participant emphasized that it is important for 
providers to be aware of diseases that may be truly be more prevalent in particular 
populations, for instance, diabetes in the Latino population. 

5. As a Healthy Start grantee, we provide trained medical 

interpreters to providers. Demand for interpreter services 
exceeds our resources, yet providers say they cannot pay for 
services on a contracted basis. How can Massachusetts' funds 
be tapped to reimburse for interpreter services? 

The panelists and meeting participants offered several options. Approaching the 
legislature for Title IV funds was one approach suggested. Also, community-based 
resources may be available, and community agencies receiving State and Federal 
funds are mandated to assist in the area of translator services. Finally, be creative 
about partnerships and alternate funding sources. 



Other Comments: 

1. Sonja Boone, MD, from Northwestern Memorial Hospital commented that to 
enhance the awareness and use of the language line, her hospital had speaker- 
phones installed in the emergency rooms and clinical units. In addition, they 
developed a formal program for minority physician recruitment. 

2. The group identified the literacy level and legalese in informing documents as 
another challenge to culturally competent services. Readability of language and 
visual presentation can limit communication to consumers. Colors, font size, 
white space, graphics, and grade level of textual material should always be 
considered and revised if necessary. 



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